|LETTER TO THE EDITOR
|Year : 2013 | Volume
| Issue : 4 | Page : 758-759
Organ conservation approach for primary mucosal malignant melanoma of the larynx
Arvind Krishnamurthy1, Vijayalakshmi Ramshanka2, Urmila Majhi3
1 Department of Surgical Oncology, Cancer Institute (WIA), 38, Sardar Patel Rd, Adyar, Chennai, India
2 Department of Molecular Oncology, Cancer Institute (WIA), 38, Sardar Patel Rd, Adyar, Chennai, India
3 Department of Pathology, Cancer Institute (WIA), 38, Sardar Patel Rd, Adyar, Chennai, India
|Date of Web Publication||11-Feb-2014|
Department of Surgical Oncology,Cancer Institute (WIA), 38, Sardar Patel Rd, Adyar, Chennai 600 020
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Krishnamurthy A, Ramshanka V, Majhi U. Organ conservation approach for primary mucosal malignant melanoma of the larynx. J Can Res Ther 2013;9:758-9
A 27-year-old woman presented to us with complaints of foreign body sensation in her throat for 2 months duration and a hot potato voice for a month. Further evaluation by means of a flexible laryngoscopy revealed a narrow pedicled, irregular polypoidal mass lesion with black pigmentation arising from the free border of the aryepiglottic fold partially obscuring the view of the laryngeal inlet, [Figure 1]a a biopsy of which was suggestive of a malignant melanoma (MM). No abnormalities of vocal cord motion were noted and there was adequate secretion clearance and swallowing and a clear airway. There was no significant cervical adenopathy. A FDG-Positron Emission Tomography (PET-CT) scan revealed an isolated metabolically active mass lesion in the right supraglottic larynx with a maximum standardized uptake value of 18.1 [Figure 1]b. Except for her serum LDH which was elevated at 774 units, her remaining hematological and biochemical investigations were normal.
|Figure 1: (a) Flexible endoscopy showing a narrow pedicled, irregular polypoidal mass lesion with black pigmentation arising from the free border of the aryepiglottic fold partially obscuring the view of the laryngeal inlet. (b) A Positron Emission Tomography (PET-CT) scan showing an isolated metabolically active mass lesion in the right supraglottic larynx with a maximum standardized uptake value of 18.1|
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The lady was extremely desirous of voice preservation. She hence, was taken up for a 532-nm pulsed potassium-titanyl-phosphate laser (KTP laser) aided endoscopic partial laryngectomy, a frozen section confirmation of negative margins in the free border of epiglottis and aryepiglottic fold was obtained [Figure 2]a. Having confirmed the final histological diagnosis of a MM, [Figure 2]b she was taken up for adjuvant external beam radiotherapy (56 Grey to the tumor bed and the neck). She remained disease free for 20 months following completion of radiotherapy. [Figure 3]a and b She subsequently presented to us with generalized body pains and on further evaluation by a bone scan was found to have multiple bony metastases; her loco regional disease remained under control.
|Figure 2: (a) Specimen photograph following endoscopic laser assisted endoscopic partial laryngectomy. (b) Section shows ulcerated squamous epithelium with sub epithelium showing tumor cells composed of fascicles of sheets of oval to spindle cells with moderate cytoplasm and hyperchromatic pleomorphic nuclei and increased mitosis. Melanin pigment is seen in the tumor cells suggestive of a malignant melanoma|
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|Figure 3: (a) Flexible laryngoscopy (during the first year follow up) demonstrating clinical remission). (b) A normal CT scan of the larynx (during the first year follow up) confirming the clinical remission|
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Mucosal melanomas of the head and neck (MMHN) are exceedingly rare, comprising <1% of all the melanomas.  They arise from the neural crest, the melanocytes being of neuroectodermal origin.  The commonest sites in the head and neck are the sino-nasal region and the oral cavity.
Melanocytes are rarely detected within the larynx; this could explain the low incidence (1.5-7.4%) of primary MM in the larynx and only about 60 cases have been reported in the literature till date.
It is often difficult to define the optimal treatment modality for MMHN due to the small number of patients in most studies with the inherent selection bias in definitive management. The traditional treatment for MMHN has been radical surgery (total laryngectomy in laryngeal primaries) with or without adjuvant radiotherapy and/or chemotherapy.  Although radical surgery offers the best chance for local control, local recurrences have been reported to occur frequently.  In contrast, malignant melanoma of the larynx has a relatively low incidence of local recurrence after surgical removal, for reasons that are not entirely clear.
Many investigators have explored the options of organ conservation approach; limited excision with or without radiotherapy or definitive radiotherapy alone. ,,, Transoral laser surgeries are being increasingly used as a part of the organ conservation strategies in the management of laryngeal cancers; many reports have demonstrated KTP lasers to be an acceptable alternative when compared to the carbon dioxide laser (CO 2 laser) in this regard. 
Radiation therapy is increasingly being used in the management of MMHN, despite of the fact that MM has traditionally been considered to be radio resistant and that the role of radiotherapy in improving the overall outcome continues to remain controversial. , The role of chemotherapy and immunotherapy continues to evolve and holds promise for the future.
In conclusion, MMHN is a rare and aggressive neoplasm, with high rates of local, regional, and distant failure. Given the rarity of the problem, firm management guidelines are difficult to establish. The optimal management is therefore unclear and clinicians are faced with a therapeutic dilemma, given that the treatment options can result in striking differences in quality of life.
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[Figure 1], [Figure 2], [Figure 3]